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Causes of Vertigo

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Assessment

A thorough history is key to assessing vertigo and dizziness.
- Determine if the vertigo is positional, constant, or related to other neurological symptoms.
Positional Testing: Use the Dix-Hallpike or Roll Test if short episodes of vertigo are triggered by head movement and there is no spontaneous or gaze-evoked nystagmus.
- Dix-Hallpike Test: Primarily used to diagnose posterior-canal BPPV (Benign Paroxysmal Positional Vertigo).
  - Turn the patient's head 45 degrees to one side while they are seated.
  - Move the patient quickly to a supine position with the head hanging slightly over the edge of the bed.
  - Observe for vertical upward or rotatory nystagmus.
  - Repeat with the head turned 45 degrees to the opposite side.
- Roll Test: Used to diagnose horizontal-canal BPPV.
  - Start with the patient in a supine position with their head on the bed.
  - Turn the head 90 degrees to one side and observe for horizontal nystagmus.
  - Both sides will show horizontal nystagmus if horizontal-canal BPPV is present.
HINTS Exam: Use to differentiate between vestibular neuritis and posterior stroke if constant vertigo and nystagmus are present.
- Three components must be present to diagnose vestibular neuritis:
  - Head Impulse Test: Look for a corrective saccade when the examiner turns the patient’s head away from the direction of spontaneous nystagmus.
  - Nystagmus: Look for unidirectional horizontal or rotatory nystagmus.
  - Test of Skew: Perform a cover-uncover test to assess for vertical or slanted eye movements. The absence of such movements supports a peripheral cause.
Central Causes: Perform a detailed neurological exam, including assessments of gait and coordination, to rule out central causes of vertigo (e.g., stroke).

Management

Peripheral Causes:
- Epley’s Maneuver: Effective for posterior-canal BPPV (PC BPPV).
- Gufoni Maneuver: Used for horizontal-canal BPPV (HC BPPV).
- Steroids: Can be considered for vestibular neuritis, although evidence supporting their use is limited.
Central Causes:
- Neuroimaging is necessary to rule out central causes such as stroke.
- Involve a neurology consult and consider stroke management as needed.

Causes	Clinical	Clinical Investigations	Management
Benign Paroxysmal Positional Vertigo (BPPV)	Short lived (20-30 secs) vertigo brought on by lying down, turning over or getting out of bed. Resolves when still. No spontaneous nystagmus	Dix-Hallpike Maneuver: Positional test to diagnose BPPV. Head Impulse Test: To evaluate vestibular function.	Epley Maneuver: Repositioning technique to move dislodged crystals in the inner ear. Brandt-Daroff Exercises: Home exercises to manage symptoms.
Meniere's Disease	Older patient. Chronic hearing loss, tinnitus and episodes of vertigo. Not positional	Audiometry: Hearing test to assess for hearing loss. Electrocochleography: To detect abnormal inner ear fluid levels. Vestibular Testing: Includes caloric testing and VEMP (Vestibular Evoked Myogenic Potentials).	Dietary Modifications: Low-sodium diet to reduce fluid retention. Medications: Diuretics, betahistine, and anti-vertigo medications. Intratympanic Injections: Corticosteroids or gentamicin for severe cases. Surgery: Endolymphatic sac decompression or vestibular nerve section in refractory cases.
Vestibular Neuritis	Hours or days of constant severe vertigo, worse with head movements. Difficult with gait. Spontaneous or gaze evoked nystagmus in first few days. Resolves over a few weeks	Clinical Diagnosis: Based on the sudden onset of vertigo without hearing loss. Head Impulse Test: To confirm a peripheral vestibular disorder.	Corticosteroids: To reduce inflammation. Vestibular Rehabilitation: Exercises to promote central compensation. Symptomatic Treatment: Antiemetics and vestibular suppressants for acute relief.
Vestibular migraine	Often under-diagnosed. Multiple episodes of dizziness lasting minutes to days. History of migraines. Half of the episodes have either typical migraine headache, and/or associated photophobia/phonophobia	Clinical Diagnosis: Based on atypical features and migrainous features. MRI To exclude stroke in some.	Corticosteroids: To reduce inflammation. Vestibular Rehabilitation: Exercises to promote central compensation. Symptomatic Treatment: Antiemetics and vestibular suppressants for acute relief.
Labyrinthitis		Audiometry: To assess for hearing loss associated with labyrinthitis. MRI or CT Scan: To rule out other central causes of vertigo.	Antibiotics: If bacterial infection is suspected. Antiviral Medications: For viral causes. Corticosteroids: To reduce inflammation. Vestibular Rehabilitation: Exercises to aid in recovery.
Central Causes (e.g., Stroke, Multiple Sclerosis)	Posterior circulation stroke - Can present similar to vestibular neuritis. May have focal paresthesia, weakness, headache or neck pain, and Deadly Ds: dysarthria, diplopia, dysmetria, dysphonia, dysphagia	MRI or CT Scan: To detect brain lesions or abnormalities. Neurological Examination: To assess for central nervous system involvement.	Neurological Treatment: Based on the underlying condition (e.g., stroke management protocols). Physical Therapy: To help with balance and coordination.

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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